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/10A,11 :A0 S- <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE•3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNI)ABL PERRMIT / CALL(209)953-7697 FOR INSPECTIONS PIRES I YEAR FROM DATAISSUED <br /> t Joe ADDRESS V 1 .I1�Vp� ) C��y V ti. CITY/ZIP I a <br /> CROSS STREET ��It,-L-/,r� ?s I���,1 APN ��1�•�� PO�� PARCELSIZE <br /> OWNER NAME �'-S-I�L�� t yF-'1 Jj--�t"1'��� �PHHO '7 <br /> ONN L-1x�.�7� <br /> OWNER ADDRESS I.- /�/-t(_ CITY/STATFJZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATFJZI P <br /> LICENSE ❑CA2 ❑C•36 OTHER NUMBER EXPIRATION DATE_ <br /> WATER TABLE DEPTH:_ R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERCTEST N BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: tak NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGtNEF.RDFSKNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS:__/) NUMBER OF BEDROOMS: L!y� NUMBER OF EMPLOYEES: <br /> ASEPTIC TANK TYPE/MFG_ CAPACITY r�V'V gilt #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal N OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION S12E TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS N OF LINE <br /> s LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL 7u I FOUNDATION_ R PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft "�I <br /> DISTANCE i0 NEARG4T WELL_ R FOUNDATIONft PROPERTY LINE R <br /> O SUMPS WIDTH ft LENGTH ft DEPTH ft O <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH_ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE JI <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND RFGULATIONSOF SAN JOAQUIN COUNTY_ <br /> MINIMUM 2rROta,DV'ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED !�!L"_� TITLE_ Q7"�t'��-- DATE <br /> c <br /> I <br /> 11 <br /> - _ T <br /> 1 <br /> c <br /> � - J A Ulf UJ <br /> 1 - M <br /> �I <br /> - DEPARTMENT US ONLY <br /> Application Aceeyted B Date �- V A. CA/ Employee ILW <br /> Final laapectlo■B Dafe 13 SPECIAL PERMIT-Approved by <br /> Character of Sall to Depth 43 Ft: PO/Sump Soil Character: <br /> COMMEI iT5 <br /> PE SC Received Chec Amount Dde Permit/ Invoice N Peradl IDN <br /> Code INV FO B Cash Remitted Service uest N <br /> +2-.it 11-7 3 Z- Ind 0 <br />